AAOMC Newsletter | Issue 3 | October 2023

CORRECTED VIEW E-TEA an AAOMC Publication

American Academy of Orthokeratology & Myopia Control

Issue No. 3 | October 2023

An image caption can describe the photo accompanying the article

President's Address Esteemed Attendees, Colleagues and Partners, I am thrilled to reflect on the resounding success of our recent Vision By Design Conference. We had the privilege of hosting a gathering of brilliant minds, including optometrists, industry partners, researchers, and innovators who are leading the charge in the field of myopia management. Our conference was not merely an event; it was a testament to the commitment and dedication of our community to improving the vision and well-being of people around the world.

One of the cornerstones of Vision By Design has always been the emphasis on collaboration and networking. It was inspiring to witness the unity and shared purpose of our attendees. The connections made here will undoubtedly pave the way for future breakthroughs in myopia management and orthokeratology. It is through such gatherings that we foster innovation and drive progress.

Our industry partners played a pivotal role in the success of this event. Their unwavering support, cutting-edge products, and commitment to research have propelled our field to new heights. We extend our heartfelt appreciation to them for their invaluable contributions.

As we look to the future, we are armed with new knowledge, fresh perspectives, and a shared sense of purpose. We are poised to make a meaningful impact on the lives of countless individuals who will benefit from the advancements in myopia management and orthokeratology.

I would like to thank each and every one of you for your unwavering commitment to our mission. Your passion, expertise, and dedication are the driving forces behind our continued success. Let us carry the spirit of this conference forward, united in our resolve to make a lasting difference in the field of myopia management.

I am already looking forward to VBD 2024, where we will once again come together to shape the future of eye care. Until then, may our shared journey be filled with discovery, collaboration, and, most importantly, improved vision for all.

Thank you for your support, and let us continue to change lives through our work.

Cheryl Chapman OD, FAAO, IACMM, FIAOMC, Diplomate ABO President, American Academy of Orthokeratology and Myopia Control

Thank You to Our Vision by Design Partners

Page 2

In This Issue

Page 1

President's Address

Page 2

Thank You to Our VBD Partners

Page 4

Certifications Tools for Your Team: Online Staff Bootcamp Now Available Managing Myopia One Child At A Time

Page 5

Marketing

Page 5

The Alignment Zone

Page 5

Case Report

Page 9

Member Spotlight

Page 10 Announcements Page 11

Practice Pearls

Page 11

Paraoptometric Tea

Page 12 Recent Publications Page 15 AAOMC Doctor Finder Page 16 Membership Resources Page 17 Tea Time with the Residents Page 19 FAQ’s About OrthoK Page 19 Spread the Love Page 20 Utilizing the Bullseye to Improve Patient Revenue Page 23 Closing Remarks

Missed the Last Issue?

No Problem!

Catch Up on the Previous Issue Today!

Issue 2 | July 2023

Certifications

Stay Up to Date!

Stay up to date by visiting the AAOMC website!

Visit AAOMC Online!

Tools for Your Team: Online Staff Bootcamp Now Available Would you enjoy not having to train staff?

Would you like to actually have a lunch break rather than train newcomers?

With staff turnover do some staff never get thoroughly trained?

Do you hear your staff give wrong answers from time to time and you cringe?

Would you like your staff to be more enthusiastic about myopia management?

Would you like your office to stand out as super competent?

If you answered YES, Weapons For Your Staff is your salvation. This program has 17 training videos, each takes about 20 minutes to view (and can be repeated over and over). There is a self-test after each video. When the series is complete, the staff member gets a prominent Purchase Today! certificate of completion.

Managing Myopia One Child At A Time AAOMC

THE CORRECTED VIEW The Corrected View Podcast

Managing Myopia One Child At A Time describes the most recent scientific advances and translates them into a unique clinical approach we call The Montreal Experience. With more than 15 years of experience in controlling myopia and treating several hundred children and young adults, the authors have developed a practical and successful approach. Using specific cases that explains their Myopia and Myopia management, taking some of the mystery out of the topic authors are providing the reader with insight and confidence to help their patients.

The Corrected View is the official podcast of the AAOMC with our hosts Dr. Anith Pillai and Dr. Dwight Barnes

Purchase the new comprehensive myopia management book today!

10% discount to AAOMC members! ($109.99 Written, $59.99 E-Book)

Catch Up On Recordings Today!

Purchase A Copy Today!

Page 4

Marketing

Social Media

Connect with us to make sure you never miss an announcement.

Check us out on our following social sites

Myopia Management for Everyone Join this unbiased patient - doctor group to see what patients are saying about myopia management

AAOMC

THE LIGNMENT ZONE The Alignment Zone A new segment brought to you by host, Dr. Paul Levine.

Join him for insight on some of your most burning questions.

Dr. Paul Levine

Dr. Julio Arroyo

The Alignment Zone

Case Report

Hyperopic OrthoK Utilizing Paragon CRT Written by Mira Sivan, OD

I chose to present this case because it doesn’t follow the expected topo maps and yet when looking carefully at all the details on the maps there is a logical explanation to how the lenses worked and transformed the cornea to allow the expected vision outcome.

50 YO female, preschool teacher with hyperopia and presbyopia, unremarkable eye and general health other than seasonal allergies.

What I offered by using ortho k lenses was clear vision most of the day without glasses at distance and near. Bonus: switching from SCLs might help with her ocular allergies.

The plan: mono-vision ortho-k: OD dominant eye for distance and OS for reading.

Mira Sivan, OD

In this presentation we’ll follow the left eye.

Page 5

MR: +1.00 -0.25 x080 20/20 Add +2.00 20/20 = total target power +3.00D sphere.

Unaided VAs at near : 20/100 OS, 20/60 OU. K Readings Pre Tx : 43.06 / 43.40 x 170 Pre Tx maps: straight forward cornea without any foreseen challenges:

such as Jessen power, RZ, LZs and edge lift are Paragon CRT standard or proprietary knowledge that will be adjusted as needed after I start the fitting process with the initial lens.

Pre Tx elevation map

Pre Tx axial curvature map

The lens created a typical hyperopic NaFl bullseye pattern on the cornea but there was a central bubble. It demonstrated adequate fit otherwise so it was dispensed. I was hoping that the central bubble will disappear by the next day, thinking that it might be an insertion technique that still needs to be mastered by the patient.

1 day F/U Unaided vision acuities at near: Before: NVA 20/100 OS, 20/60 OU. After: NVA 20/30 OS 20/30 OU.

The initial Paragon CRT lens design was based on the parameters of the topographer K readings, the calculated monovision Rx (OS +3.00D sph) and HVID. After providing an in depth explanation including the fact that this is an “off label” fitting and setting her vision expectations with monovision the following trial lens was ordered Paragon CRT 7.1 500 -33 10.5 -0.50D OZD 6mm I started with the standard Tx zone size and planned to see if it needs to be adjusted since it might negatively affect her night vision. This will require a delicate balance of night/day and near/far vision. All the other initial parameters Page 6

On the first morning after using the lenses overnight, there is not much change at the center of the cornea and a RZ ring within the pupil margin.

The good, This seemed to be a pretty good start after using the lens for one night from the visual perspective.

The Bad, Although objectively we achieved an overall good visual outcome after 1 night subjectively the patient felt that her vision was blurrier.

And the ugly… I still couldn’t eliminate the central bubble so, I ordered a new lens to reduce the sag.

2nd trial Lens: 7.1 500 -32 10.5 Well centered lens with a typical hyperopic bullseye NaFl pattern, without the central bubble this time, Yey!

Lens demonstrated good fit on the cornea with a typical Hyperopic bullseye NaFl pattern. Corea still looked nice and healthy on SLE. Subtractive Tangential Maps

1 week F/U: 7.1 500 32 10.5 -0.50D Unaided acuities : Before: NVA 20/100 OS, 20/60 OU. After: NVA 20/25 OS, 20/25 OU Subtractive Tangential Map

The subtractive tangential map shows a center treatment area that looks FLATTER than the pretreatment curvature based on the dioptric / color scale but when looking at the flat and steep K dioptric values of the main meridians, it’s actually slightly steeper by about +0.25D. The RZ steepening creates a plus power ring of about +1.75D within the pupil margin. This can explain the better visual results (distance and near), Plan: Since vision improved, cornea looked nice and healthy and contact lens fit looked adequate, the patient was instructed to keep using the lenses and RTC in 2 weeks. At this point I was hoping that all we needed was extra time.

On her 2.5 wks F/U she. came in after removing the lenses for about 8 hours. Unaided acuities : 20/30 at near OS, 20/20 at near OU.

2.5 wks F/U 7.1 500 -32 10.5 -0.50D 10.5 The tangential subtractive map looks very similar to the previous one only this time the Flat and Steep K main meridians readings are both steeper than the pre treatment flat and steep Ks when looking at the color- power scale, which created a plus power effect centrally of about +0.75D and the dark cool blue color changed to green- lighter blue. The RZ ring area is still within the pupillary margin, which contributes to the nice plus power effect in the paracentral area of the pupil, which in other words helps create the bifocal epithelial lens with center distance, periphery near effect.

My Plan: Since cornea looks nice and healthy and vision keeps improving patient is to keep using the lenses and is to RTC in 1 month for a follow up.

Patient kept delaying and came in for a F/U after 2.5 months.

Patient came in after she took the lenses out 7 hours ago.

Unaided acuities: D 20/20 OS, 20/20 OU N 20/25 OS, 20/20 OU Patient said that her vision has been good even though she was only using her left lens for near vision correction lately. She used the glasses we provided her with (+0.75) only sometimes. She was pretty happy with her vision at this point.

I used this case as a learning opportunity and asked her to RTC in another 2 wks which makes it 3 month F/U.

Page 7

I saw her after removing lenses about 8 hours prior to visit time. Average wearing time: 6-7 hours / 4-5 days per week Unaided acuities: D 20/25 OS, 20/20 OU N 20/25 OS, 20/20 OU At this point she was very happy with the vision outcome we got. She enjoys the freedom from her glasses and not having any exacerbation of the environmental allergies she had with the SCLs and is hardly using any low power readers.

Typical Hyperopic bullseye NaFl pattern with good centration and movement.

The tangential subtractive map shows a well centered lens with mildly steeper flat Ks ( 43.06 to 43.76) and mildly steeper steep Ks (43.40 to 43.88) at the central cornea in comparison with the pre-treatment Ks. The RZ once again shows a complete and pretty well centered treatment ring that created the plus power in the range of 45.00D 50.00D compared with around 43.00D pretreatment and it’s within the pupil margin. Both of these essentially created a bifocal epithelial lens with center distance power of +0.75 and peripheral near power of +2.5D add on average, gained from the flattening of the annulus around it. Also the central cornea is slightly more sphericalized based on the delta of the flat and steep Ks before (-0.35D) VS after ( -0.12D).

Page 8

So what do we have at this point? good looking fit on the eye, great vision (both distance and near).

Refraction was +1.00 with +2.00 Add. Corneal power gained by the OK lens: +0.50 to +0.75D centrally ( at the BOZ area) and about +2.50D add power at the paracentral cornea ( at the RZ area) after removing the lenses about 7 hours at the time of the exam and NOT even using the lenses every single night of the week.

Obviously, patient and I were very happy with the visual outcome.

What I’ve learned from this?

Similar to myopia control we are using the RZ plus power for our benefit. In this case we can use it to get additional, significant plus power that provides simultaneous distance and near vision - achieved if the RZ is within the pupillary margin. So, essentially we get a modified MonoVision fit.

In summary, although this was not the typical hyperopic topo maps as expected of significant central steepening of the cornea, since the cornea looked nice and healthy and patient enjoyed clear vision distance and near with the epithelial center distance, periphery near power lens, I was happy with the outcome just as much as was the patient (if not more). When fitting hyperopic, presbyopic patients we help them make their dream vision come true overnight with clear vision at distance and near most of the time. With them too, I see improved confidence, athletic performance, less dry eyes as well as less environmental allergic symptoms compared with SCLs and just a general more positive outlook on life. Most get used to the night glare caused by these lenses, because they are highly motivated.

My theory as to what causes the topographic changes as they presented in this case: Since in hyperopic OK lenses there are 2 alignment curves, they are creating a massive pressure on both sides of the RZ which in return pulls epithelial cells and liquids from the periphery of the cornea and the paracentral and even central cornea till the RZ reaches a point of equilibrium with the adjacent cornea. After that point, when there’s continuous pressure, now the epi cells will be pushed towards the center of the cornea till there is equilibrium there as well. I would be very happy to hear the experts opinion about this.

Member Spotlight

Dr. Dwight Barnes, O.D., FIAOMC, IACMM

Dwight Barnes, O.D., FIAOMC, IACMM Cary Family Eye Care Cary, NC

Family/Education: I grew up in Wilson, NC, about an hour east of Raleigh. My parents still live in Wilson, which is great because it’s close enough to visit easily. After attending a very small high school, I really wanted to go to a large university. My older brother was a student at the University of North Carolina at Chapel Hill. After visiting him a couple of times I fell in love with the school and its campus, and I decided to go to school there. I majored in Biology, with a Chemistry minor, and after graduation I attended Southern College of Optometry in Memphis, TN. When I graduated, I had no idea that I would one day specialize in myopia management. I did a primary care residency at a VA hospital in Boston, MA, and gained a tremendous amount of experience in managing ocular disease. I met my wife, Kelly, while in optometry school in Memphis. Kelly also did a residency in Boston, and we got married right after finishing our residencies. My plan had always been to return to North Carolina.

Fortunately, Kelly also was interested in living in NC, so we moved back to start our optometry careers. We have two children, Nate (17 years old) and Ella (14 years old).

My family is super important to me. In addition to my wife and children, my brother and his wife live only about 15 minutes away.

How Did I get into Optometry: Growing up, I had poor vision. I started wearing glasses in kindergarten. As a young myopic child, I needed to get regular eye exams and update my glasses yearly…exactly the same scenario we see with many of our patients. I knew I was interested in some type of medical career, and I always considered optometry. I liked my optometrist growing up and enjoyed my visits to his office.

"As a young myopic child, I needed to get regular eye exams and update my glasses yearly… exactly the same scenario we see with many of our patients."

As I progressed through college, I gradually decided that optometry was the field for me.

Career Journey: As we started our careers, my wife and I decided that we did not want to immediately work together. As much fun as we thought that might be, we wanted to forge our own professional paths in eye care. We each worked for separate private practice optometry clinics in rural NC. After 5 years, we decided that we’d like to open our own clinic. I don’t think any practice owner would say that the process is “smooth sailing”. There are always challenges. Practice ownership can be frustrating but it is also very rewarding.

There are plenty of mistakes that I’ve made along the way, but I can’t imagine just working for someone else. I really enjoy practice ownership.

Our practice is Cary Family Eye Care. We are an independent practice at the western edge of Cary, NC. We like to say that we are “fiercely independent”. Our goal is to improve the quality of life for our team, our patients, and our community. There are a few things that make our practice unique. Several years ago, we created our Myopia Control Clinic, which functions like a “clinic within a clinic”. We’ve gradually developed specific branding and marketing to help us grow this specialty. Building a positive office culture is super important to us. We utilize open book management with our entire team. Everyone on our team knows our collected revenue, our occupancy costs, our COGS, and other expenses. This helps them to have a real impact on the success of our office. We try hard to create opportunities for our team to grow into leadership positions within our office. Our integrator (like a practice administrator) has been with us for the past 7+ years and helps us to keep a successful office culture and hold our team accountable to our core values. Our practice is celebrating our 15th anniversary this year, but we still have big plans for the future!

We’re moving this year into a larger facility that will allow us to continue to grow, and we’re adding a Vision Therapy clinic to help us meet the needs of our local community.

Page 9

My passion for myopia management and orthokeratology comes from my own history. I watched my own prescription increase every year as I was growing up. My prescription eventually reached -12.50. My axial length is over 29mm. I’ve had retinal laser treatment for lattice degeneration. With my history, I consider myself very fortunate to be correctable to 20/20 in both eyes. When I started to learn about myopia management I became very interested. When I started fitting ortho-k, I found it to be a really fun challenge. As I saw the benefit these treatments had for my young patients, I was hooked. Today, I no longer see new routine patients unless they are specifically interested in myopia management options.

I love seeing the joy and confidence that children get by learning how to put in and take out ortho-k molds by themselves, and by seeing clearly for school and other activities without glasses. I also enjoy seeing how happy their parents are knowing that they’ve done something that will have a positive impact on their child’s future!

Announcements

Meet the AAOMC‘s Executive Director Megan!

Megan Schoenfelder, CASE

Megan is the Executive Director for the AAOMC. Megan’s role is to support the board and the members of the association, including responding to member inquiries, planning Vision by Design, supporting the Board with decisions and ensuring the organization runs smoothly. In her free time, Megan enjoys time with her family in Gig Harbor, WA which includes her husband Nick, her 6-year old daughter Quinn and 4-year old twin daughters Reese and Jordan.

If you have any questions, recommendations or comments, please feel free to reach out to Megan with any needs that you may have.

Megan Schoenfelder 253-525-5152 megan@aaomc.org

Meet the AAOMC‘s Events Manager Natasha!

Natasha is the Events Manager for AAOMC. Natasha works alongside the Executive Director to plan the annual conference, Vision By Design. She specializes in creative and strategic planning, problem-solving, and event growth. Natasha enjoys creating and building relationships between the Natasha Gunia organization and the vendors that help bring VBD together.

She has a passion for people. In her free time, Natasha enjoys volunteering with her local Rotary Club, attending community events, and spending time with her family. She loves the lake life on Lake Tapps in Washington state, but enjoys every opportunity to travel as well.

Practice Pearls If you have two siblings in orthok, make one set a different color so they do not get mixed up.

- Nathan Bonilla-Warford, OD, FAAO, FCOVD, FIAOMC

Get axial length measurement method sooner.

- Nathan Bonilla-Warford, OD, FAAO, FCOVD, FIAOMC

Myopia control compliance gets more difficult in high school and WAY more difficult in college. This is due to patient independence, schedule, and visual needs (esp driving). Educate about all this the year before it goes into effect so it is not a surprise and you are justified if you need to make a change (such as switching out of orthok).

- Nathan Bonilla-Warford, OD, FAAO, FCOVD, FIAOMC

Have A Practice Pearl You Would Like to Share?

Send Your Peals to megan@aaomc.org

Paraoptometric Tea Interview with Paraoptometric with Emily Tauriello Tell us a little something about your story.

Hi, I'm Emily! I’ve been working in this field for a little over 6 years and I’ve worked with Dr. Sivan for the past 3 years.

Emily Tauriello

Tell us a little bit about your role in your practice?

I work for a private practice so we are on the smaller side.

This has given me the opportunity to get a very well rounded education in the world of optometry. Everyday I’m doing something a little different with the overall goal to provide the best care possible for our patients.

How did you get interested in working in the field of optometry?

When I was 14 I visited my local optometrist with some unusual symptoms and was diagnosed with white dot syndrome. Thanks to that visit I was offered a job with that same optometrist. That visit also aided in my diagnosis of multiple sclerosis 2 years later. This grew my passion even more and helped me understand just how valuable of a role our eyes play in our general health.

Are there any challenges that you have had to overcome in your career journey?

My age! Starting in this field very young made it a challenge to be taken seriously by my peers. I even had difficulty getting permission to take my certification test because they had never had anyone under 18 ask to take it before. I made a plea to the board to let me become certified and they approved it. While this was a setback at first I’ve realized now how grateful I am to already have years of experience at a young age.

What do you believe is the most important thing you do to support your doctor and your practice?

I think keeping communication flowing between myself and the doctors I work with can make or break a patient experience. It’s important that patients know that they are heard and their complaints are not being ignored. Taking note of what patients are saying during their pre-testing and making the doctor aware of their concerns will make the doctor prepared to care for their patient and the patient Page 11 feel valued.

Have A Membership Nomination for the Paraoptometric Spotlight?

Send Your nomination to megan@aaomc.org

What do you believe is the most important thing you do to support your doctor and your practice?

Working with kids is definitely my biggest inspiration. My favorite feeling is the day after a kid starts ortho-k for the first time. It’s exciting to be able to show the patient and their parents how much their vision improved in just one night.

What is one piece of advice that you would give to a paraoptometric that is working in a practice that offers Myopia Management services?

To learn as much as you possibly can. Don’t just learn how to do something, learn why you are doing it. It adds an incredible amount of enjoyment and purpose to your work.

How do you manage to balance your career and your personal life/family?

I’m thankful to work for a doctor that appreciates her staff not only as employees but as people. Having a boss that respects and encourages a work life balance has made this extremely easy.

Recent Publications

with Dr Langis Michaud and Dr. Patrick Simard Article 1 : Defocus incorporated multiple segments (DIMS) spectacle lenses increase the choroidal thickness: a two-year randomized clinical trial RKM Chun, H Zhang, Z Liu, DYY Tse, Y Zhou… - Eye and Vision, 2023 Purpose: This study aimed to investigate the effect of DIMS spectacle lenses on subfoveal choroidal thickness (SfChT) over a period of two years.

Methods: This study involved a secondary analysis of our previous randomized clinical trial. Myopic school-aged children aged 8–13 years were recruited in a two-year study investigating the effect of DIMS spectacle lenses on myopia progression. The treated group received DIMS spectacle lenses (n=78), while the control group was treated with a pair of single vision (SV) spectacle lenses (n=80).

SfChT was monitored at 1 week, 1, 3, 6, 12, 18 and 24 months post lens wear using spectral-domain optical coherence tomography and a custom made autosegmentation algorithm utilizing convolutional neural networks.

Results: SfChT increased significantly after one week of DIMS spectacle lens wear compared to those wearing SV spectacle lenses (adjusted mean change relative to baseline ±SEM at one week; DIMS vs. SV, 6.75±1.52 µm vs.−3.17±1.48 µm; P< 0.0001, general linear model). The thickness of choroid increased to 13.64±2.62 µm after 12 months of DIMS lens wear while the choroid thinned in SV group (−9.46±2.55 µm).

Choroidal changes demonstrated a significant negative association with axial elongation over two years in both the DIMS and SV groups. Choroidal change at three months significantly predicted the changes in AL at 12 months after controlling the effect of age and gender.

Dr Langis Michaud OD M.Sc. FAAO (Dipl) FBCLA FSLS FEAOO FIACMM

Dr Patrick Simard, OD, MSc, MBA, FAAO, FBCLA, FIACLE, IACMM unia

Conclusion: Our study demonstrated a significant choroidal thickening in response to myopic defocus incorporated in a spectacle lens after one week of lens wear, sustained over the two-year study period.

The results suggested that choroidal changes at three months may help predict changes in axial length after one year.

Langis and Patrick Clinical Translation: Although not available in the USA, anti-myopia glasses are available elsewhere in the world. The authors report here on an interesting analysis that predicts the long-term results (2 years) of Defocus incorporated multiple segment technology (DIMS), based on 3-month data.

Points to remember : It is a randomized, double-blind study with impeccable protocol and control group Glasses had to be worn by both groups full-time Measurement of the choroid was carried out appropriately, using OCT and ensuring that measurements were always taken in the same place, and controlling environmental conditions The results indicate that DIMS generates choroidal thickening as early as the first week of wear, and gradually increases over the first 18 months. Thickening is maintained at all times up to 24 months. Defocus acts rapidly.

These results are similar to the effect of atropine on the choroid.

The change observed at 3 months predicts the change in axial length at 2 years.

This may provide a new method for determining the best intervention strategy for children.

Article 2 : Optical changes and association with axial elongation in children wearing orthokeratology lenses of different back optic zone diameter B Guo, P Cho, SW Cheung, R Kojima, S Vincent - Eye and Vision, 2023 Purpose: To compare changes in ocular aberrations in children wearing orthokeratology (ortho-k) lenses with a back optic zone diameter (BOZD) of 6 mm (6MM group) or 5 mm (5-MM group) and their associations with axial elongation (AE) over two years.

Methods: Seventy Chinese children, aged 6 to < 11

years, with myopia between − 4.00 to − 0.75 D, were randomly allocated to 5-MM and 6-MM groups.

Ocular aberrations were measured, rescaled to a 4-mm pupil, and fitted with a 6th order Zernike expansion. Measurements, including axial length, were taken prior to commencing ortho-k treatment and then every six months over two years.

Results: After two years, the 5-MM group displayed a smaller horizontal treatment zone (TZ) diameter (by 1.14 ± 0.11 mm, P < 0.001) and less AE (by 0.22 ± 0.07 mm, P = 0.002) compared with the 6-MM group. A greater increase in total root mean square (RMS) of higher-order aberrations (HOAs), primary spherical aberration (SA) (C04), and coma were also observed in the 5-MM group at all follow-up visits. The horizontal TZ diameter was significantly associated with changes in RMS HOAs, SA (RMS, primary and secondary SA), and RMS coma. After controlling for baseline parameters, RMS HOAs, RMS SA, RMS coma, and primary (C04) and secondary (C06) SA were significantly associated with AE. Conclusion: Ortho-k lenses with a smaller BOZD created a smaller horizontal TZ diameter and a significant increase in total HOAs, total SA, total coma, and primary SA and a decrease in secondary SA. Of these ocular aberrations, total HOAs, total SA, and primary SA were negatively correlated with AE over two years.

Langis and Patrick Clinical Translation: The debate about the effectiveness of OK lenses by optical zone has been raging for several years.

This study is another contribution to the debate.

The methodology is rigorous, and factors that could confound the results have been eliminated.

It is therefore a reliable study.

Compared to other studies, the authors validated the effects of a smaller zone on the cornea, and indeed found differences between a 5 mm and a 6 mm optical zone. In particular, the horizontal diameter of the treatment zone on the cornea is smaller, which is less obvious vertically. The lens used is the BE, so the conclusions can only apply to it.

Page 13

The smaller zone was associated with more total high-order aberrations (X2), spherical aberrations (X3), coma (x2). on the other hand, secondary spherical aberrations were reduced.

which is in line with previous studies about blur sensitivity. Defining whether the differences derive from retinal processing or anatomical features of a myopic eye requires further investigation. Our approach might be a first step to explain how nearwork promotes the eye’s elongation.

Higher aberrations level is negatively associated with axial length progression. This means that higher levels control eye elongation better.

The effects were felt for the first 6 months, after which the difference remained stable. It seems that the benefits of a smaller zone appear quickly but do not increase over time. They are maintained. In this sense, short-term results are predictive of long-term effects.

Langis and Patrick Clinical Translation: It's one thing to assert that reading or prolonged close-up work contribute to myopia, but it's quite another to decipher the mechanism underlying this relationship. This article takes a closer look at the impact of the optical stimulus on the retina via the angle of on and off patterns. From psychological study, it was shown that myopia is related to changes in the sensitivity to ON/OFF stimulation, which mainly concerns amacrine or ganglion cells.

When the OFF pathway predominates, the choroid thins, and myopia progresses, particularly if the eye is already myopic. This is the case when black text is read against a white background.

The authors were able to demonstrate that the region most sensitive to these variations in stimulation is located at 6-12 degrees in the perifoveolar zone. This proves that the retinal response mechanism to optical stimulus differs between the fovea and the peripheral zone, with the latter producing a more intense and differentiated response.

Article 3: Impact of text contrast polarity on the retinal activity in myopes and emmetropes using modified pattern ERG S Wagner, T Strasser - Scientific Reports, 2023 Environmental factors favoring myopia development are still being studied and there is accumulating evidence for a significant role of nearwork. Recently, reading standard black-onwhite text was found to activate the retinal OFF pathway and induce choroidal thinning, which is associated with myopia onset. Contrarily, reading white-on-black text led to thicker choroids, being protective against myopia. Respective effects on retinal processing are yet unknown. Here, we exploratively assessed the impact of contrast polarity on the retinal activity and possible interactions with eccentricity and refractive error. We recorded pattern electroretinograms in myopic and emmetropic adults while presenting a dead leaves stimulus (DLS), overlaid by masks of different size in ring or circle shape, either filled with uniform gray or text of inverted or standard contrast. In myopes, retinal responses for DLS with standard and inverted contrast were larger when the perifovea was stimulated (6–12 deg), however, including the fovea resulted in smaller amplitudes for inverted contrast than in emmetropes. The retina of emmetropes was more sensitive to inverted contrast than to standard and gray within 12 deg, but most sensitive for gray in the perifovea. This demonstrates that the refractive error influences the sensitivity to text contrast polarity, with a special role of the peripheral retina, Page 14

To sum up: text contrast influences retinal response It seems that the on and off pathways dictate this response via amacrine and ganglion cells Myopes react differently from emmetropes, notably due to the change in photoreceptor configuration as the eye lengthens the most sensitive area is between 6 and 12 degrees from the fovea Reversing reading and screen contrasts could be a simple way to help curb myopia Article 4: Emmetropization and non myopic eye growth. (Review article) J Rozema, S Dankert, R Iribarren- Survey of Ophthalmology, 2023 Most eyes start with a hypermetropic refractive error at birth, but the growth rates of the ocular

components, guided by visual cues, will slow in such a way that this refractive error decreases during the first 2 years of life. Once reaching its target, the eye enters a period of stable refractive error as it continues to grow by balancing the loss in corneal and lens power with the axial elongation.

Although these basic ideas were first proposed over a century ago by Straub, the exact details on the controlling mechanism and the growth process remained elusive. Thanks to the observations collected in the last 40 years in both animals and humans, we are now beginning to get an understanding how environmental and behavioral factors stabilize or disrupt ocular growth. We survey these efforts to present what is currently known regarding the regulation of ocular growth rates.

AAOMC Doctor Finder

Have you updated your information on the AAOMC Doctor Finder since the new website was launched?

Doctor Finder

Our new Doctor Finder even allows practitioners to denote which lenses they are comfortable fitting to make transfer of care a smoother, easier process.

Langis and Patrick Clinical Translation: The ocular growth and visual development follows 3 stages: hypermetropization, emmetropization and homeostasis.

Myopia is developed as a consequence of a loss of homeostasis Eye growth is dictated by retinal response, mostly second to the detection of the blue Figure 12 showing an overview of the processes affecting emmetropization during the passive eye growth phase (0 to 2 years old) and summarizes the interaction between lens power, corneal power, and axial length.

Later in life (3 years old and older), active eye growth is dependent on the global retinal detection, the parasympathetic nervous system, the pupil size, the ocular wavefront error, the local retinal blur, the local retinal detection (photoreceptor sensitivity and ON/OFF pathways), the temporal integration and the local growth response via the choroid and the sclera.

All those factors are influenced by the environment (ambient illuminance, chromaticity, and spatial frequency content) and the behavior of the accommodation system.

Considering the number of significant factors involved in the process, it is unlikely that a unique mechanism will be enough to stabilize a growing myopic eye.

Page 15

Membership Resources Job Match Tool is Live!

We hear you! Membership has asked for ways to connect with potential job seekers/ employers. The AAOMC is here to help everyone find the best fit and opportunities. Check out our new Job Match Tool that has been integrated into our website.

Job Match Tool

For members, there's a dedicated section where you can post job listings and manage your own posts. Note that while members can only manage their own listings, all job posts are visible to the public.

It’s accessible from the “Home” dropdown menu in the public view

It’s also located in the bottom header

Job seekers can apply by emailing their resumes directly to the job poster’s email address.

Google Group Have you signed up?

Be an active participant or just watch and learn with this interactive community of experts. If you are missing out on this valuable member resource, email megan@aaomc.org to join the Google Group today.

Page 16

Tea Time with the Residents

Which is Better, 5 or 6?

Written by Melynda Gagliardi, OD, FAAO

Melynda Gagliardi, OD, FAAO

Orthokeratology are reverse geometry gas-permeable contact lenses designed to correct myopic refractive errors via temporary corneal reshaping. Back optic zone diameter (BOZD) directly influences the corneal treatment zone size (TZS); an important parameter in facilitating the myopia control benefit of orthokeratology. TZS is the size of the area of corneal flattening assessed on topography and was revealed in a study from the University of California Berkeley to be smaller than the BOZD by an average of 0.38mm, with a large individual variation.1 Some manufacturers allow for specific customizations. However, standard BOZD are 5mm and 6mm. So which do you select?

A randomized crossover study from the University of California Berkeley examined subjects over a 4-week period with a 5mm BOZD in one eye and a 6mm in the other.1 After a 1-2 week washout, the parameters were switched and monitored over another 4-week period.1 The study concluded the 5mm BOZD had a faster onset of correction at days 1 and 7 and a smaller corneal treatment zone.1 The Variation of Orthokeratology Lens Treatment Zone (VOLTZ) Study, a prospective randomized clinical trial, determined the 5mm design had a smaller treatment zone and slower axial elongation at one year, without a compromise in visual quality, corneal staining or lens binding.2 The myopia control mechanism for orthokeratology is not well understood but it is hypothesized that induced aberrations are responsible. The main contributory aberrations suspected are spherical and other high-order aberrations such as coma.3 Spherical aberrations are off-axis rays that do not fall on the same plane as on-axis rays. Myopic progression occurs due to induced peripheral hyperopic defocus which signals for axial elongation. Directing the aberrations to the peripheral retina, creates myopic defocus and prevents the signaling for growth.3 A study evaluating induced aberration over a 6mm pupil showed a 3fold increase in total high-order aberrations, a 6-fold increase in spherical aberration alone, and a 2-fold increase in comatic aberration post-treatment.3 Smaller treatment zone sizes have been seen to be more effective at controlling myopic progression due to more aberrations within the pupil inducing retinal defocus.1 Studies have examined the relationship between pupil size and axial elongation theorizing that larger pupil sizes also mimic this effect of higher retinal defocus and show more efficacy with treatment.3,4 Pupil size is not a common parameter accounted for in research protocols. However, this may be attributed to disparities between studies and should be considered moving forward.3 A retrospective study at the Tianjin Medical University Eye Hospital examined the relationship between corneal topographic appearance and myopia progression.4 Topography scans were reviewed for 352 children assessing treatment zone size and centration with axial elongation over 12 months.4 They concluded a smaller TZS and larger decentration of the treatment zone resulted in the smallest progression of axial length (0.06mm over 1 year) compared to a larger TZS and a more centered lens (0.23mm over 1 year).4 Although decentration was also revealed to aid in preventing axial elongation, intentional decentration was not recommended due to visual discomfort such as ghosting, glare, and visual fatigue.4 Therefore, if decentration is observed with no adverse effects impacting the patient’s quality of vision, it is a parameter that may benefit axial length stabilization in the long term. Decentration is thought to improve myopia control efficacy via increased comatic aberration, similar to a smaller treatment zone size.3 Greater lens decentration and higher magnitude of refractive error corrected were seen to induce more aberration with orthokeratology treatment.3 For high refractive errors, visual quality may be improved with a 5mm BOZD since the corneal flattening is spread over a smaller corneal area.

Page 17

Orthokeratology is thought of first for its myopia control benefit and, therefore, children are the primary demographic. However, it is a great option to present to all age groups including the presbyopic population. Adult myopic progression can be seen into their late twenties, regardless of socioeconomic status and education level.5 The mechanism of action is thought to be the same as progression in childhood and therefore, orthokeratology can also play a role in myopia reduction.5 Adults can also benefit from orthokeratology purely for its refractive correction. Orthokeratology is a great alternative for patients living active lifestyles who have built contact lens intolerance from dry eye symptoms or overwear and for those hesitant to consider surgical laser vision correction or are not candidates but still seek independence from spectacles or daily wear contact lenses. In these cases, a larger BOZD would alleviate the potential consequences of the induced aberration such as minimizing glare and distorted vision.

Orthokeratology provides temporary myopic correction to allow for unaided daytime correction with myopia control benefits. I typically select the 5mm BOZD for myopia control patients in order to maximize peripheral defocus in order to control axial elongation. For adult orthokeratology patients who are using this modality for refractive error, I usually select a 6mm BOZD. However, every patient should be treated on an individual basis depending on their history, refractive error, pupil size, visual demands, expectations, and motivations.

References 1. Jung, L., Liu, M. (2022, January). Comparing 5mm and 6mm Back Optic Zone Diameter (BOZD) in Orthokeratology Lens Design [Poster Presentation]. Global Specialty Lens Symposium, Las Vegas, NV, USA. 2. Guo, B., Cheung, S.W., Kojima, R., Cho, P. One-year results of the Vairaiton of Orthokeratology Lens Treatment Zone (VOLTZ) Study: a prospective randomised clinical trial. Ophthalmic Physiol Opt. 2021; 41: 702-714. https://doi.org/10.1111/opo.12834.

3. Lau JK, Vincent SJ, Cheung S-W, Cho P. Higher-order aberrations and axial elongation in myopic children treated with orthokeratology. Invest Ophthalmol Vis Sci. 2020;61(2):22. https://doi.org/10.1167/iovs.61.2.22 4. Lin W, Li N, Gu T, Tang C, Liu G, Du B, Wei R. The treatment zone size and its decentration influence axial elongation in children with orthokeratology treatment. BMC Ophthalmol. 2021 Oct 12;21(1):362. doi: 10.1186/s12886-021-02123-x. PMID: 34641799; PMCID: PMC8513184.

5. Lee SS, Mackey DA. Prevalence and Risk Factors of Myopia in Young Adults: Review of Findings From the Raine Study. Front Public Health. 2022 Apr 27;10:861044. doi: 10.3389/fpubh.2022.861044. PMID: 35570945; PMCID: PMC9092372.

Page 18

FAQ’s About OrthoK Written by Rochelle Tang, CMN

Rochelle Tang CMN

Here are some frequently asked questions that often come up during our consultations with patients and their families when we introduce OrthoK treatment. We provide these answers to ensure a clear and mutual understanding of how we can assist in improving their child's vision.

How does Ortho-K work?

Ortho-K lenses are kind of like braces for the eyes, where the lens gently exerts pressure on the cornea, flattening it slightly to change the way light enters the eye. This reshaping temporarily corrects myopia (nearsightedness).

Is Ortho-K permanent?

No, the effects of Ortho-K are temporary. If you stop wearing the lenses regularly, your cornea will gradually return to its original shape, and your vision will revert to its previous state.

Is Ortho-K safe?

When fitted and maintained correctly, Ortho-K lenses are safe. However, like any contact lenses, improper use or hygiene can lead to eye infections or other complications. Regular follow-ups with your eye care provider are essential.

How long does it take to see results?

Most people experience improved vision within a few days to a few weeks of starting Ortho-K treatment.

The full effect may take a few weeks to stabilize.

What do you mean my child can see clearly in the morning after a night of ortho-k wear?

When your child wears Ortho-K lenses overnight, they gently reshape the front surface of the eye. This reshaping temporarily corrects their myopia allowing your child to experience clear vision without the need for glasses or daytime contact lenses. The effect is temporary and typically lasts throughout the day. Regular nightly wear of Ortho-K lenses is necessary to maintain this improved daytime vision.

Can I still wear glasses or regular contact lenses with Ortho-K? In most cases glasses and daily wear contact lenses are not necessary. However if you require glasses in addition to your Ortho-K lenses your doctor will help determine the most suitable eyeglass prescription. It is not advisable to wear daily contact lenses if you are wearing Ortho-K lenses as your eyes need a chance to breathe during the day.

What happens if I miss a night of wearing Ortho-K lenses?

Occasionally missing a night is acceptable but the vision the next day will be slightly blurred.

Remember to have the best outcome with Ortho-K the lenses should be worn every night.

Spread the Love Know a Doctor or Paraoptometric that you think would enjoy the camaraderie and benefits of The AAOMC? Invite Them to Join!

Utilizing the Bullseye to Improve Patient Revenue Written by Tom Chapman, CEO, Peeq Pro https://peeqpro.com/

There are roughly twenty steps within an optometric practice interaction with a customer. This is the patient or customer journey. However, not each of these steps is as valuable from a patient education, adoption, and purchasing perspective. The most important part of the transaction is the offset bullseye represented in Figure 1.

Tom Chapman, CEO, Peeq Pro

The “bullseye” includes the steps that take place from the moment the patient sits down in the doctor’s chair to the point that the patient checks out of the office. At Peeq Pro, we call this the “bullseye” because it is the most impactful and important part of the patient interaction that drives patient decision making and behaviors. An office looking to increase revenue from improved sales and marketing practices will see its results in the bullseye.

In the bullseye, it is critical that the doctor execute three specific conversations.

1. Diagnose the problem. What is the problem - dry eye, myopia, glaucoma, etc. Explain the problem in terms the patient can understand - including tiebacks to current symptoms when possible. For example, rather than saying to a patient - “you have inflammation around the meibomian gland causing ocular surface challenges”, instead say - “the discomfort that you are feeling is due to your eyelid glands not being able to make good tears”. This may be an imperfect description - but it is one the patient can understand. Don’t lean so heavily into the science that you fail to communicate the problem.

2. Clearly and with intention recommend a mitigation (if not a solution) - eyelid hygiene, IPL, orthokeratology, medicine, etc. Explain what can be done. For example, we use a dry eye protocol that provides eye drops for short-term relief and a variety of tools for longer term improvement - such as a warm compress or eyelid hygiene device (such as the Peeq Waiva).

Figure 1.

3. Effectively hand off to staff with clarity around both #1 & #2. It is important that the handoff be verbally comprehensive (not reliant on charts) and articulated with products and names - such as “our dry eye protocol provider is Peeq Pro”. Peeq actually recommends that the patient receives a card that identifies for staff the challenge and solution. This acts as a priming activity for the patient to realize a further action will be taken by staff at checkout (i.e. they are going to be buying the solution). For example, here is the dry eye card that Peeq recommends for doctors and then for patients. Notice the change in vocabulary without degrading the message.

Page 20

Peeq Pro has been using the card in figure 2 to help with dry eye communication to the patient. This card helps doctors and staff translate the problem to the patient - discomfort caused by ocular surface disease as established by DEWS II research. This card explains the problem Figure 2. to a non-doctor patient without dictating a one size fits all solution.

Instead, while it primes the patient to purchase a dry eye protocol, it does not prohibit more advanced solutions for patients - such as an in-office treatment, like an intermittent pulse laser.

One key reason this is effective is that the doctor is a trusted advisor on health purchases. For example, a recent study showed that doctors and nurses remain the most trusted source of product recommendations (67% for doctors compared "a recent study showed that doctors to 13% for social media). Thus, when a doctor clearly recommends and nurses remain the most trusted a solution to a patient regarding their discomfort, the patient is source of product recommendations more likely to purchase than continue to browse a variety of (67% for doctors compared to 13% for inadequate solutions on the internet. Frequently, we see doctors social media)." push sales to staff because they do not like to portray themselves as a sales person. But, the reality is that if the doctor believes in the remedy - they should make sure the right products get into their patients’ hands. Staff’s role is to ensure that it is 1) not dropped because of poor communication (don’t rely on charts alone) and 2) is re-iterated through the next couple of transactional steps, to 3) culminate in a clear expression of the doctor’s plan at checkout. But, staff’s role is not to sell a patient on the remedy. The patient does not trust the staff in the same way that they trust the doctor.

That being said, the staff can definitely increase sales volume in an office. One best practice that we have seen in offices is what we call the “fries offer”. At the end of a fast food transaction, it is commonplace to ask - do you want fries with that burger. What are the ‘fries’ offers in your clinic?

For example, do you want to improve eyelid hygiene "One best practice that we have seen (which according to most written materials is step one in in offices is what we call the “fries improving dry eye)? If so, does your staff ask at checkout - “Do offer”. At the end of a fast food you want to include an eyelid cleanser with your contacts today? transaction, it is commonplace to ask It is an important way to avoid dry eye and discomfort if you - do you want fries with that burger." commonly wear contacts.” This simple closing statement can often turn a no thought no sale into the sale of a useful product.

In particular, products such as hypochlorous acid and tea tree oil cleanser are good examples of products that doctors sell in this way.

Page 21

One alternative that we have seen is using the fries order to improve recall rates. There are multiple ways to do this. But, two that complement each other are to ask the patient to follow the office on Facebook or Instagram AND to re-appoint the patient in twelve months.

The best offices execute the bullseye well. They have the highest per patient product revenue streams by living in the bullseye with execution of product and service recommendations.

There are many ways to improve your bullseye process and increase the transactional revenue with patients.

Peeq believes that it's not just about increasing sales…it's increasing sales that have positive impacts on avoiding additional diseases and the progression of diseases. You are providing a service - like a dentist helping a patient to avoid cavities. You should be happy to help a patient have cleaner eyelids, not afraid or nervous about a patient spending an additional $25 in your office.

Page 22

Closing Remarks

What Do We Know About OrthoK? Written by Michael J. Lipson OD FAAO FSLS

Michael J. Lipson OD FAAO FSLS

Orthokeratology has come a long way since the days of daytime wear of flat spherical lenses.

Technological advances have propelled the practice to a very safe, controlled process of prescribing precisely manufactured high-dK, multi-zone reverse geometry lenses. Scientific study of numerous aspects of OrthoK has allowed us to “know” many things. That said, there are many things we think we know about OrthoK and others that are yet to be proven or understood.

What We Know about OrthoK - Strong Clinical and Irrefutable Scientific Evidence OrthoK is a viable alternative modality to daytime contact lenses, spectacles and refractive surgery to correct refractive error. It temporarily induces central epithelial change that results in topographical changes that reduce or eliminate refractive error. 1,2 These changes also create the optical effect of spherical aberration. Multiple studies have shown that a well-centered treatment zone maximizes the overall quality of vision when the lenses are removed. 3 There are multiple methods of fitting OrthoK (empirical, diagnostic and topography-based) that have been found to be successful. We know that myopic children wearing OrthoK show slower axial elongation than those wearing spectacles or traditional contact lenses. 4,5,6 Although the potential for serious complications due to overnight wear exists, those events have been shown to be very rare (about 7 in every 10,000 pt-yrs of wear). 7 Because no vision correction is required during the day, vision-related quality of life is better with OrthoK than with other modes of vision correction. 8

But, it may not be ideal for every patient. Those who do not wear lenses regularly will experience fluctuations in vision.

What we think we know about OrthoK - Strongly Suggestive Evidence-Additional Studies required (What we want to believe) Extensive study has allowed us to accept that the “relative peripheral myopic defocus” created by OrthoK is the mechanism that slows axial elongation. 9 But, that does not prove that other undiscovered mechanisms may also contribute to the effect. In our quest to select ideal candidates for OrthoK, specific patient attributes have been proposed as predictive for success. The popular targets are K readings, pupil size, corneal eccentricity and corneal biomechanics. Results from studies performed on each of these attributes have been mixed. 10 Since the effect of OrthoK has been shown to be primarily on corneal epithelium, the three attributes above may have minimal influence on the end result. Recent studies have targeted the back optic zone diameter (BOZD) and the resulting treatment zone diameter (TZD) as parameters that impact axial elongation. 11 Results strongly suggest that smaller TZD’s produce slower axial elongation than larger ones. To date, this finding has been found to be “associated” with slower axial elongation but not necessarily causative. In addition, a number of coincident factors may have an influence on the finding (width of the “red ring”, width of the reverse and alignment curve, asphericity of the base curve, TZ decentration…). Obviously, extensive additional study is needed to answer this question as well as why have we seen good myopia control with “standard” BOZD’s prior to these studies. 12 What we don’t know about OrthoK - Need more research We know there are limits to the amount of refractive error we can correct with OrthoK but we don’t really know what those limits are. It may be due to limitation in the lens design or limits of the cornea. In addition, we don’t know why some patients respond better or worse to refractive changes or slowing of axial elongation than expected. Relative to slowing of axial elongation, if relative peripheral myopic defocus is the primary Page 23

mechanism, we have yet to determine the magnitude or the location of that defocus that provides the maximum efficacy. Therefore, we have not identified precise factors to allow us to make OrthoK even more efficacious than it is currently in slowing axial elongation.

Some studies have shown that axial elongation is slower in cases where the TZ is decentered. 13 It is not known if this is because there is greater myopic defocus in specific areas or due the creation of more aberrations. Other issues still in question are whether there are stromal changes induced during OrthoK (mixed results from a handful of studies) and are there other attributes that can make OrthoK even safer than it is now (materials, coatings, supplemental drops, disinfecting solutions…).

Those of us who prescribe and manage OrthoK patients KNOW that patients love it! They love the freedom from correction during waking hours and parents love seeing their child’s rate of myopia progression slowed. In this age of high tech, we have seen amazing changes in what technology can do. Continuing research on OrthoK may provide answers to some of our unknowns. This will undoubtedly lead to improvements that further benefit our patients.

CORRECTED VIEW E-TEA an AAOMC Publication

American Academy of Orthokeratology & Myopia Control

Page 24

References 1. Faria-Ribeiro M, Belsue RN, Lopez-Gil N, Gonzalez-Meijome JM. Morphology, topography, and optics of the orthokeratology cornea. J Biomed Opt 2016;21:075011.

2. Swarbrick HA, Wong G and O’Leary DJ. Corneal Response to OrthoKeratology. Opt Vis Sci.1998;75:791-799.

3. Liu G, Chen Z, et al. Effects of Myopic Orthokeratology on Visual Performance and Optical Quality. Eye Cont Lens.2016;44:316-321.

4. Charm J, Cho P. High myopia-partial reduction orthokeratology (HM-PRO): study design. Cont Lens Anterior Eye 2013;36:164–70.

5. Santodomingo-Rubido J, Villa-Collar C, Gilmartin B, et al.

Myopia control with orthokeratology contact lenses in Spain: refractive and biometric changes. Invest Ophthalmol Vis Sci 2012;53: 5060–5.

6. Cho P and Cheung S-W. Retardation of Myopia in Orthokeratology (ROMIO) Study: A 2-Year Randomized Clinical Trial. Invest Ophthalmol Vis Sci. 2012;53:7077–7085.

7. Bullimore MA, Sinnott LT, and Jones-Jordan LA. The Risk of Microbial Keratitis With Overnight Corneal Reshaping Lenses. Optom Vis Sci 2013;90:937-944.

8. Lipson MJ, Boland B, McAlinden C. Vision-related quality of life with myopia management: A review. Cont Lens Ant Eye.2022;45:101538.

9. Smith EL, et al. Effects of Local Myopic Defocus on Refractive Development in Monkeys. Optom Vis Sci 2013;90:1176-1186.

10. Chen X, et al. Factors determining the myopia control effect of an orthokeratology lens: A two-year multi-level model.

Ophthal Physiol Opt. 2022;42:786–796.

11. Variation of Orthokeratology Lens Treatment Zone (VOLTZ) Study: A 2-year randomised clinical trial. Ophthal Physiol Opt. 2023;00:1–13. DOI:10 .1111/opo.13208 12. Bullimore MA and Liu M. Efficacy of the Euclid orthokeratology lens in slowing axial elongation. Cont Lens Ant Eye.2023; 13. Chen R, Chen Y, et al. The effect of treatment zone decentration on myopic progression during orthokeratology, Current Eye Research.2020;45:645-651.

DOI:10.1080/02713683.2019.1673438

Issue No. 3 | October 2023